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Transcript of SURGERY FOR TGA AND LVOTO - shaconferences · DYNAMIC LVOTO IN TGA TGA AND LVOTO DYNAMIC LVOTO IN...
SURGERY FOR TGA AND LVOTOLVOTO
Thomas L. Spray, M.D.
Chief, Cardiothoracic SurgeryAli L d W E d d Ch iAlice Langdon Warner Endowed ChairThe Children’s Hospital of Philadelphia
Professor of SurgeryProfessor of SurgeryUniversity of Pennsylvania
TGA WITH LVOTO-TGA AND LVOTO
TGA WITH LVOTODEFINITION
• TGA/IVS Or VSD With PV Abnormalities• TGA/IVS Or VSD With Subvalvar
LVOTO• TGA/IVS With Dynamic LVOTO• TGA/IVS With Dynamic LVOTO• TGA/VSD With Coarctation/Arch
HypoplasiaHypoplasia• Taussig-Bing Heart (Arch Obstruction)
DYNAMIC LVOTO IN TGA
TGA AND LVOTO
DYNAMIC LVOTO IN TGA• Caused By Septal Shift Seen Only In• Caused By Septal Shift – Seen Only In
TGA/IVS• More Common When Aorta Anterior And• More Common When Aorta Anterior And
Leftward• SAM Can Contribute To Gradient• SAM Can Contribute To Gradient• ASO Alone Reliably Relieves Obstruction
M b Si ifi t L t P bl Aft• May be Significant Late Problem After Atrial Switch
FIXED LVOTO IN TGA
TGA AND LVOTO
FIXED LVOTO IN TGA
P l V l Ab liti• Pulmonary Valve Abnormalities• Subvalvar Fibrous Membrane• Subvalvar Fibromuscular Tunnel• Septal Malalignment• Accessory Mitral Or Tricuspid Valve
Tissue• Anomalous Insertion Of MV On
Infundibular Septum (Straddle)
LVOTO IN TGA SURGICAL
TGA AND LVOTO
LVOTO IN TGA-SURGICAL OPTIONS
• ASO, Resection Of LVOTO • Atrial Switch Resection Of LVOTO• Atrial Switch, Resection Of LVOTO
Or LV-PA Conduit• Rastelli Or REV Procedure• Nikaidoh-Bex Procedure• Nikaidoh-Bex Procedure• Single Ventricle Repair (Fontan-
Kreutzer)
PULMONARY VALVE
TGA AND LVOTO
PULMONARY VALVE ABNORMALITIES
• May Occur With IVS Or VSD• Unequal Cusp Sizes And Bicuspid Valves, q p p ,
Dysplasia, Commissural Fusion• Abnormal PV May Not Be Obstructivey• May Result In Neoaortic Insufficiency/
Root Dilation• Rare For PS To Be Isolated; Usually In
Association With Complex SubAS, PV p ,Annular Hypoplasia (Rastelli)
TGA AND LVOTO
ASO WITH PV HYPOPLASIA AND
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
ASO WITH PV HYPOPLASIA AND BICUSPID PV
From: Park, C S, et al. JTCVS 2010;139:135-8
TGA AND LVOTO
ASO WITH PV HYPOPLASIA AND BICUSPID PVThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
ASO WITH PV HYPOPLASIA AND BICUSPID PV
From: Park, C S, et al. JTCVS 2010;139:135-8
SUBVALVAR FIBROUSTGA AND LVOTO
SUBVALVAR FIBROUS MEMBRANE
• Seen In IVS And VSD• Seen In IVS And VSD• Usually Resectable
SUBVALVAR FIBROMUSCULAR TUNNEL• Seen In IVS And VSD• Often Associated With Hypoplastic PVOften Associated With Hypoplastic PV• Difficult To Resect• Rastelli/REV Nikaidoh-Bex (Konno)Rastelli/REV, Nikaidoh Bex (Konno),
ASO All Options
ACCESSORY TV TISSUETGA AND LVOTO
ACCESSORY TV TISSUE• May Be Present With VSD, Usually Not
Outlet Typeyp• Prolapses Into LVOT• Usually Resectable Or Excluded By VSDUsually Resectable Or Excluded By VSD
PatchACCESSORY MV TISSUECC SSO V SSU
• Usually Seen With IVS, Rarely VSD (ECD Tissue)(ECD Tissue)
• Mitral Tissue Tags/ Accessory Tissue• Usually Resectable Without Damage ToUsually Resectable Without Damage To
Valve
TGA AND LVOTO
SEPTAL MALALIGNMENT
• Deviation Of Outlet Septum Into LVOTLVOT
• Seen Only In TGA/VSDy• Difficult To Resect
i i O G O i• Nikaidoh-Bex Or REV Good Options
ABNORMAL VALVETGA AND LVOTO
ABNORMAL VALVE INSERTION
Ab l Att h t MV Ch d O• Abnormal Attachment MV Chordae Or Pap Muscle To Outlet Septum
• Straddling TV• May Not Preclude ASO, VSD Closure, But
Resection May Not Be Possible• Various Techniques Such As Nikaidoh-Bex q
May Be Necessary• Single Ventricle Approach If Severe MV• Single Ventricle Approach If Severe MV
Abnormalities
ARTERIAL SWITCH/LVOTO TGA AND LVOTO
OPTIONS
From: Sohn, et al. Ann Thorac Surg 1998;66:842-8
ASO WITH LVOTOTGA AND LVOTO
ASO WITH LVOTO• Sohn, et al. Ann Thorac Surg
1998 66 842 81998;66:842-826 Pts. Mean Age 69 Days Mean Wt. 4.5
Kg.Bicuspid PV - 4, Dysplastic PV – 5LVOT Abnormalities – 17Preop Gradient 30 mm Hg (0-93)p g ( )Death – 2 (7.7%), No Late DeathsFreedom From Reop 87% @ 130 mo.Freedom From Reop 87% @ 130 mo.Gradient At Followup 0 mm Hg.
TGA AND LVOTO
ARTERIAL SWITCH/LVOT RESECTION-CAUSE OF OBSTRUCTION
From: Sohn, et al. Ann Thorac Surg 1998;66:842-8
TGA AND LVOTO
ARTERIAL SWITCH/LVOT RESECTION-GRADIENT ON FOLLOWUP
From: Sohn, et al. Ann Thorac Surg 1998;66:842-8
ASO WITH RESECTION LVOTO
TGA AND LVOTO
ASO WITH RESECTION LVOTO
• Sharma et al Ann Thorac SurgSharma et al. Ann Thorac Surg 2002;74:1986-91
23 i A 90 4 323 Pts., Median Age 90 Days Wt. 4.3 Kg.2 Early Deaths8 Pts. Mild AR At DischargeMean Followup 60 Months4/8 (50%) AR Progressed To Moderate Or Severe At Followup
RASTELLI PROCEDURE FOR TGA AND LVOTO
TGA/LVOTO• Kreutzer, et al. JTCVS 2000;120:211-23
101 Pts. Median Age 3.1 Yr., Wt. 12.6 Kg.PS - 73, Pulm. Atresia – 18 7 Early Deaths (7%)Risk factors For Death – Straddling TV, Long X-
ClampMedian FU 8.5 Yr. – 17 Late Deaths, 1 TransplantLate Reop/Arrhythmias/Sudden Death Common
TGA AND LVOTORASTELLI PROCEDURE-
PATIENT CHARACTERISTICS
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTO
RASTELLI PROCEDURERASTELLI PROCEDURE
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTO
RASTELLI PROCEDURE-RASTELLI PROCEDURESURVIVAL
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTO
RASTELLI PROCEDURE-RASTELLI PROCEDURESURVIVAL BY ERA
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTO
RASTELLI PROCEDURE-RASTELLI PROCEDUREFREEDOM FROM REINTERVENTION
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTORASTELLI PROCEDURE-
LVOT, RVOT REINTERVENTION
From: Kreutzer, et. Al. JTCVS 2000;120:211-23
TGA AND LVOTO
RASTELLI AND VSD ENLARGEMENTRASTELLI AND VSD ENLARGEMENT
From: Navabi, MA et al. JTCVS 2009;138:390-6
TGA AND LVOTO
RASTELLI AND VSD ENLARGEMENTThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
RASTELLI AND VSD ENLARGEMENT
From: Navabi, MA et al. JTCVS 2009;138:390-6
TGA AND LVOTO
RASTELLI AND VSD ENLARGEMENTThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
RASTELLI AND VSD ENLARGEMENT
From: Navabi, MA et al. JTCVS 2009;138:390-6
TGA AND LVOTO
RASTELLI AND VSD ENLARGEMENTThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
RASTELLI AND VSD ENLARGEMENT
From: Navabi, MA et al. JTCVS 2009;138:390-6
REV PROCEDURETGA AND LVOTO
(REPARATION A L’ETAGE VENTRICULAIRE)
• Extensive Resection Of Conal Septum +/• Extensive Resection Of Conal Septum +/-VSD Enlargement
• Direct Reimplantation Of Pulmonary• Direct Reimplantation Of Pulmonary Trunk On RV
• LeCompte Maneuver• LeCompte Maneuver• VSD Size And Abnormal TV Attachments
To Septum Not Limiting LessTo Septum Not Limiting – Less Recurrent LVOTO
• No Conduit Reoperation Less Likely• No Conduit – Reoperation Less Likely Despite PR
TGA AND LVOTO
RASTELLI VS LECOMPTE(REV)RASTELLI VS LECOMPTE(REV)
From: Lee, et al. Eur JCTS 2004;25:735-41
RASTELLI VS LECOMPTE(REV)
TGA AND LVOTO
RASTELLI VS LECOMPTE(REV)
From: Lee, et al. Eur JCTS 2004;25:735-41
TGA AND LVOTO
RASTELLI VS LECOMPTE(REV)( )
From: Lee, et al. Eur JCTS 2004;25:735-41
TGA AND LVOTO
RASTELLI VS LECOMPTE(REV)RASTELLI VS LECOMPTE(REV)
From: Lee, et al. Eur JCTS 2004;25:735-41
TGA AND LVOTO
AORTIC TRANSLOCATION VS RASTELLIThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
AORTIC TRANSLOCATION VS. RASTELLI
From: Morrell, VO et al. Ann Thorac Surg 2005;79:2089-93
TGA AND LVOTO
AORTIC TRANSLOCATION (NIKAIDOH-BEX)AORTIC TRANSLOCATION (NIKAIDOH BEX)
From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90
TGA AND LVOTO
AORTIC TRANSLOCATION (NIKAIDOH-BEX)AORTIC TRANSLOCATION (NIKAIDOH-BEX)
From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90
TGA AND LVOTO
AORTIC TRANSLOCATION (NIKAIDOH-BEX)AORTIC TRANSLOCATION (NIKAIDOH-BEX)
From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90
TGA AND LVOTO
RASTELLI REV OR NIKAIDOH?RASTELLI, REV OR NIKAIDOH?
From: Hu, S, et al. JTCVS 2008;135:331-8
TGA AND LVOTO
AORTIC TRANSLOCATIONThe image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
AORTIC TRANSLOCATION
From: Hu, S, et al. JTCVS 2008;135:331-8
TGA AND LVOTO
MODIFIED REV PROCEDUREMODIFIED REV PROCEDURE
From: Hu, S, et al. JTCVS 2008;135:331-8
TGA AND LVOTO
PREOPERATIVE CHARACTERISTICSPREOPERATIVE CHARACTERISTICS
From: Emani, SM, et al. Circulation 2009;120:S53-58
TGA AND LVOTO
LATE COMPLICATIONSLATE COMPLICATIONS
From: Emani, SM, et al. Circulation 2009;120:S53-58
TGA AND LVOTO
FREEDOM FROM LVOT REINTERVENTIONFREEDOM FROM LVOT REINTERVENTION
From: Emani, SM, et al. Circulation 2009;120:S53-58
SUMMARYTGA AND LVOTO
SUMMARY• Surgical Results Good – Low Mortality, Similar To
TGA/VSD• TGA/VSD Or TGA/IVS With Isolated PV
Abnormality – ASOTGA/VSD/IVS With S b al ar Obstr ction Choice Of• TGA/VSD/IVS With Subvalvar Obstruction – Choice Of
Operation Varies Based On Resectability Of LVOT, PV Annulus Size
• Nikaidoh-Bex Useful For VSD/PS With Moderate PV Hypoplasia Or Septal Malalignment
• Rastelli/REV For Pulmonary Atresia, Significant Valvar y , gPS And Hypoplasia –REV May Have Less Reop
• Results With Rastelli Suboptimal – LVOTO & Conduit Changes CommonChanges Common
• Late Function Of AV And Root Still Unknown
TGA AND LVOTO
QUESTIONSQUESTIONS• When is PV too small for ASO?• What is long-term function of bicuspid PV?• Is the fate of the AV and root same as in Ross
operation?• Is the aortic valve at more risk for late AR after aorticIs the aortic valve at more risk for late AR after aortic
translocation?• Is coronary transfer with aortic translocation
i t d ith l t l i / t i ?associated with late occlusion/stenosis?• Is the REV operation associated with less LV
dysfunction and recurrent LVOTO than the Rastelli?
• Is VSD enlargement technique at Rastelli or REV associated with long-term survival?associated with long term survival?
• Will REV patients all require PV implantation late?